Rheumatic fever and its heart complication, rheumatic heart disease, cause 400,000 deaths annually mainly among children and young adults. At least 12 million people are estimated to be currently affected by the disease with two million patients requiring repeated hospitalization and one million requiring, often unaffordable, heart surgery in the next five to 20 years.

"We don't hear much about the disease outside heart disease specialists," says Dr Porfirio Nordet of the World Health Organization's (WHO) Department of Noncommunicable Diseases Prevention. "Almost exclusively, it affects children from poor families in developing countries who can hardly afford even a single dose of penicillin a month". If there are no complications, monthly injections of penicillin should go on for five years, while more serious cases will require life-long penicillin treatment and heart surgery.

Asia, Africa, Latin America and the eastern Mediterranean regions are the four geographical areas that suffer the most with up to 1% of all schoolchildren showing signs of the disease. WHO has the evidence that the disease can be prevented with a few genuinely cost-effective measures. A list of recommendations was drawn up at a consultation held this week at WHO headquarters in Geneva under the chairmanship of Professor Edward Kaplan of the University of Minnesota, USA.

"Children and especially poor children have neither money nor votes. There is no vaccine and there won't be one for at least the next ten years," explains Dr Kaplan. "But rheumatic fever/heart disease is the most preventable of all cardiovascular diseases, and a small financial injection to the national health services would go a long way towards keeping the disease under control." For example, an investment of US$ 50 000 per year for five years can ensure coverage for the programme in a district with 300 000 school-age children and prevent more than 500 rheumatic heart disease cases with its severe and costly consequences.

Rheumatic fever or rheumatic heart disease develops as a result of untreated bacterial (streptococcal) respiratory infection. On top of that, some children are more susceptible than others. It affects mostly the valves and muscle of the heart and can cause chronic illness among young people who survive. Environmental and social factors play a crucial role in the development of the disease. A combination of overcrowding, damp conditions, especially during the rainy season in tropical and sub-tropical countries, coupled with poverty and overstretched health services produces fertile ground for circulation of the infection. The most susceptible age group is school-age children from five to 19 years of age.

WHO stresses the importance of primary and secondary prevention, that is early detection and correct treatment of streptococcal sore throat or pharyngitis which would block the initial attack of acute rheumatic fever. The second line of defence is long-term penicillin treatment. When properly applied, 75% of patients recover completely. According to Dr Santiago Guzman, of the Philippine Heart Centre, supply of free penicillin is probably the biggest problem in developing countries.

"We are dealing mostly with patients from the low income groups. A monthly injection of penicillin costs the equivalent of US$3 which is way beyond their means. As a result, only 40% of patients continue treatment if they buy the medicine themselves as opposed to 85% of those who receive penicillin free of charge. National health authorities are doing their best but the budget blanket is too thin and small to cover all the needs."

WHO and its partners are looking for ways of mounting school education campaigns both for teachers and for their pupils. There is also a need for better training of health personnel at the local health centres and in laboratories. "February is a "Heart Month" in the Philippines", explains Dr Guzman "We get free air time on radio and TV for our promotional programmes but we need something similar closer to the rainy season when the incidence goes three times higher".

The WHO global programme for the prevention of rheumatic fever and rheumatic heart disease is fully operational in 22 developing countries. Reports from Costa-Rica, Cuba, Guadeloupe, Kuwait and Martinique speak of remarkable reduction in the number of new cases and recurrence attacks as well as in the morbidity, disability and mortality figures.

"The main aim of this project is to support Ministries of Health in establishing national prevention programmes in those countries where rheumatic fever and rheumatic heart disease are serious health problems", explains Dr Nordet. "We still have a long way to go before we turn it into a genuinely global programme but little by little more and more countries are joining this initiative. Time will come when we'll be speaking of the disease in the past tense."